Before a doctor can diagnose your condition and design a treatment plan, a complete history and physical examination are necessary. There are so many possible internal causes of pain; it is important to determine what is and is not causing the problem. To make this determination, your doctor will take a complete physical history of your condition and perform a physical examination.
The complete physical history may begin by your doctor asking you to fill out a written form that asks you a number of questions relating to your pain. The more information you share, the easier your problem will be to diagnose.
Your physical history is important because it helps your doctor understand everything about your pain including when it began, any injury that could have caused it, whether your lifestyle or any physical factors might have caused it, and whether you have a family history of similar problems.
After reading through your physical history, your doctor may ask more questions that relate to the information you have given. These questions may include:
- When did the pain begin?
- Was there an injury that could be related to the pain?
- Where do you feel the pain? What is the intensity?
- Does the pain radiate to other parts of the body?
- What factors make the pain feel better or worse?
- Have you had problems with your bladder or bowels?
- Is there a history of osteoporosis in your family?
The physical examination helps your doctor determine what may, and what may not, be causing your pain. The areas of your body that will be examined depend upon where you are experiencing pain, such as in your neck, lower back, buttocks, arms, or legs.
During a physical examination, your doctor may check for:
- Motion of your spine and neck – Is there pain when you twist, bend, or move? If so, where? Have you lost some flexibility?
- Weakness – Your muscles will be tested for strength. You might be asked to try to push or lift your arm, hand, or leg when light resistance is put against them.
- Pain — Your doctor may try to determine whether you have tenderness of certain areas.
- Sensory Changes – Can you feel certain sensations in specific areas of your feet or hands?
- Reflex Changes – Your tendon reflexes might be tested, such as under your kneecap and under the Achilles tendon on your ankle.
- Motor Skills – You might be asked to do a toe or heel walk.
- Special Signs — Your doctor may check for any “red flags” that could indicate something other than a spinal problem. For example, tenderness in certain areas, a fever, an abnormal pulse, chronic steroid use (which leads to loss of bone mass), or rapid weight loss, may indicate your spinal problem is being caused by something else.